Scaling Up Human Resources for Health. A Situational Analysis of Government Clinical Officer and Clinical Assistant Training Institutions in Tanzania

Transcription

1 Scaling Up Human Resources for Health A Situational Analysis of Government Clinical Officer and Clinical Assistant Training Institutions in Tanzania

2 Scaling Up Human Resources for Health A Situational Analysis of Government Clinical Officer and Clinical Assistant Training Institutions in Tanzania March 21 THE UNITED REPUBLIC OF TANZANIA Ministry of Health and Social Welfare

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4 TABLE OF CONTENTS EXECUTIVE SUMMARY... 1 INTRODUCTION, BACKGROUND, AND METHODS... 4 INTRODUCTION... 4 BACKGROUND... 5 Defining the Health Workforce Crisis... 5 Scaling up at Health Training Institutions... 6 Shortages of Clinical Faculty... 8 Geographic Maldistribution of Health Workers... 8 The Importance of Mid-Level Cadres... 9 Clinical Officers and Clinical Assistants in Tanzania... 1 METHODS...12 Data Collection Analysis Limitations FINDINGS SUMMARY OF OVERALL FINDINGS Inadequate Resources for Scale-Up Limited Numbers of Local Students Severe Shortage of Full-Time Faculty Over-Reliance on Part-Time Faculty...21 Shortages of Accommodation for Students...21 Insufficient Classroom and Laboratory Infrastructure Limited Funding Available Significant Investments Needed for New Programs INSTITUTION-SPECIFIC FINDINGS & RECOMMENDATIONS Kibaha Clinical Officer Training Centre Kilosa Clinical Officer Training Centre Lindi Clinical Officer Training Centre Mafinga Clinical Officer Training Centre Mtwara Clinical Officer Training Centre Kigoma Clinical Assistant Training Centre Masasi Clinical Assistant Training Centre Maswa Clinical Assistant Training Centre...41 Musoma Clinical Assistant Training Centre Songea Clinical Assistant Training Centre Sumbawanga Clinical Assistant Training Centre... 47

5 Mbeya Assistant Medical Officer Training Centre Mpanda Clinical Assistant Training Centre...51 RECOMMENDATIONS & CONCLUSIONS Recommendations for Scale-Up Recommendations for Recruitment & Faculty Development Recommendations CONCLUSIONS...57 REFERENCES CITED APPENDIX 1: Summary of Institution-Specific Recommendations & Findings... 6 APPENDIX 2: Data Collection Tools APPENDIX 3: Full Institution Reports...74

6 ACKNOWLEDGMENTS The International Training and Education Center for Health (I-TECH) undertook this assessment with funding from the President s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) Cooperative Agreement No. 6 U91 HA 681, in collaboration with the U.S. Centers for Disease Control and Prevention s Global AIDS Program (CDC/GAP) Tanzania. Sincere appreciation goes to the Ministry of Health and Social Welfare (MOHSW), Directorate of Human Resource Development for their continuous support and collaboration and especially for identifying and allowing staff to participate in the assessment teams. Special thanks also go to Suzzane McQueen and Angela Makota of CDC/GAP for their support and guidance. We would like to acknowledge the contributions of the following individuals, who provided documents, interviews, and/or questionnaires for this report: Dr. Bumi Mwamasage and Ms. Eliaramisa Ayo from Human Resources Development (HRD), MOHSW; the principals and staff at Kibaha Clinical Officers Training Centre (COTC), Kilosa COTC, Lindi COTC, Mafinga COTC, Mbeya Assistant Medical Officers Training Centre (AMOTC), Mtwara COTC, Kigoma Clinical Assistant Training Centre (CATC), Masasi CATC, Maswa CATC, Musoma CATC, Songea CATC, Sumbawanga CATC, Mpanda CATC, Nzega Nurses Training Centre (NTC), Nachingwea NTC, and Kibondo NTC; the Medical Officer in Charge and staff of Nachingwea Hospital, Masasi District Hospital, Lingui District Hospital, Lindi District Hospital, Sumbawanga Regional Hospital, Mpanda District Hospital, Kilosa District Hospital, Tumbi Special Hospital, Mara Regional Hospital, Kigoma Maweni Regional Hospital, Mafinga District Hospital, Maswa District Hospital, Mbeya Referral Hospital, and Songea Regional Hospital. The authors would also like to sincerely thank Mr. Ndementria Vermund, Veronica Mpazi, Mr. Dennis Busuguli, Dr. Sadock Ntunaguzi, and Dr. Edward Kija for taking the time to participate in the assessment teams that collected the data for this report. Their contributions were crucial to the information presented here. Emily Bancroft and Dila Perera led the teams that collected and analyzed all data for this report. Emily Bancroft wrote the final report, with additional writing and editing by Dila Perera. Dr. Flavian Magari, Alyson Shumays, Katy Potter, Ryoko Takahashi and Kathyrn Karnell provided additional editing and input. For more information about this report, please contact: Dila K. Perera, HRHS Programme Manager Flavian Magari, Country Director International Training and Education Center for Health (I-TECH) Department of Global Health, University of Washington Ali Hassan Mwinyi/Kilimani Road, Ada Estate, Kinondoni P.O. Box Dar es Salaam, Tanzania Office: Fax: University of Washington Please seek the permission of the I-TECH before reproducing, adapting or excerpting from this report.

7 ABBREVIATIONS & ACRONYMS AIDS AMO AMOTC CA CATCs CDC CDC/GAP CIDA CO COP COTCs CSSC CTC DL EN FGD GFATM HRD HRH HRHS HIV HRSA HTI IMAI I-TECH MAMM MDGs MO MOHSW MSNT MUHAS NACTE NTA NTC Nuffic NPC PEPFAR PHSDP POPSM RMA RMOs TB ZHRC Acquired Immunodeficiency Syndrome Assistant Medical Officer Assistant Medical Officer Training Centre Clinical Assistants Clinical Assistant Training Centres Centers for Disease Control and Prevention Centers for Disease Control and Prevention/Global AIDS Program Canadian International Development Agency Clinical Officer Country Operational Plan Clinical Officer Training Centres Christian Social Services Commission Care and Treatment Clinic Distance Learning Enrolled Nurse Focus Group Discussion Global Fund for AIDS, Tuberculosis, and Malaria Human Resources Development Human Resources for Health Human Resources for Health Scale-up Human Immunodeficiency Virus Health Resource and Services Administration Health Training Institutions Integrated Management of Adolescent and Adult Illness International Training and Education Center for Health Mpango wa Maendeleo wa Afya ya Msingi (Primary Health Services Development Programme) Millennium Development Goals Medical Officer Ministry of Health and Social Welfare Muhimbili School of Nurse Teachers Muhimbili University of Health and Allied Sciences National Council for Technical Education National Technical Awards Nurses Training Centre Netherlands Organization for International Cooperation in Higher Education Non-physician clinician President s Emergency Plan For AIDS Relief Primary Health Services Development Programme President s Office of Public Services Management Rural Medical Aide Regional Medical Officers Tuberculosis Zonal Health Resource Centre

8 EXECUTIVE SUMMARY The International Training and Education Center for Health (I-TECH) is providing technical assistance, with funding from the Centers for Disease Control (CDC) Tanzania, to the Ministry of Health and Social Welfare (MOHSW) and the US government on strategies to meet the MOHSW s goals to scale-up enrollment and increase the output of new health care workers. The MOHSW has asked all health training institutions in Tanzania to increase their enrollment by 1 percent, and mid-level cadres, such as clinical officers (CO), clinical assistants (CA), and enrolled nurses (EN), are key target cadres because of their importance to primary health care services. In order to recommend specific strategies for increasing the enrollment at pre-service health training institutions, data are needed on the current barriers and opportunities to scaling-up enrollment at existing institutions. The purpose of this I-TECH assessment is to provide institution-specific data on the twelve public CO and CA institutions, in order to assist the MOHSW in determining the most effective way to increase the output of this cadre of health care workers. This assessment had the following objectives: To document the existing capacity for student enrollment and retention at MOHSW clinical officer and clinical assistant pre-service training institutions To identify opportunities to increase both short-term and long-term enrollment and retention capacity at government CO and CA institutions To document factors limiting short-term and long-term enrollment and retention capacity at visited institutions To recommend interventions necessary to overcome limiting factors. Methods The assessment was conducted between July and August of 29. Teams comprised of one I-TECH representative and one Ministry of Health representative visited all twelve public clinical officer and clinical assistant training institutions, including one new clinical assistant training institution that is scheduled to open in 21. One of the teams also visited one assistant medical officer (AMO) training institution that had been identified as a possible site for a new CO training program. Prior to the visit by the team, an Institutional Questionnaire was sent to the principal of each visited institution to collect data on student enrollment trends, infrastructure available on campus, finances, and staffing. The teams spent one day at each institution conducting a semi-structured interview with the principal or acting principal at the institution and a focus group discussion with students when available. The team also toured the facilities to document the infrastructure and visited the local hospital to interview the medical officer in charge or the acting medical officer in charge. Findings In general, there are four potential barriers to increasing enrollment at any specific institution: 1) number of tutors and staff; 2) classroom capacity; 3) dormitory capacity; and 4) other infrastructure issues which often included sanitation systems, power and water supplies, and space for growth 1

9 and expansion. Each institution has its own combination of these barriers to overcome, and therefore each institution has its own unique opportunities and potential for scale-up, which are documented in institution-specific findings and recommendations. The team also documented some key overall findings and themes cutting across all of the institutions. These findings include: Severe Shortage of Full-Time Faculty: The shortage of full-time faculty is the most important barrier to scale-up for most institutions and for students. More than 75 percent of the institutions identified the shortage of full-time faculty as the most important factor to address in order to scale-up enrollment. Inadequate Resources for Scale-Up: Although institutions have been asked to increase their enrollment by the MOHSW, most have reached their limit of enrollment with their current infrastructure. With very few exceptions, additional scale-up will require an investment in infrastructure and staffing. Limited Numbers of Local Students: Studies in both low-income countries and high-income countries have shown that health professionals recruited from rural areas are more likely to practice in rural areas in the future. Despite these findings, there are still limited mechanisms for recruiting and enrolling local students defined as students from the region where the institution is located in CO and CA programs and the number of local students varies greatly between institutions. Over-Reliance on Part-Time Faculty: As a result of the shortage of full-time faculty, many institutions rely heavily on part-time tutors to fill staffing gaps. Although crucial to health professional education, part-time tutors have more demands on their time, are less likely to have experience and training in teaching methods, and are not substitutes for the support provided to students by full-time faculty. Shortages of Accommodation for Students: Most of the CO institutions have increased their enrollment by adding a third student to dormitory rooms originally built for two students. This has led to severe overcrowding in some institutions and is not a sustainable solution for scaling up enrollment. Insufficient Classroom and Laboratory Infrastructure: With only a few exceptions, both the CO and the CA institutions are now enrolling between 5-6 students per class. Classrooms built for 4 students are overcrowded, limiting the quality of instruction provided. Limited Funding Available: All institutions reported that the funds received through cost-sharing and the MOHSW are not sufficient to maintain the institution. As a result, the food for students and curriculum modules such as computer instruction, integrated management of adolescent and adult illnesses (IMAI), and fieldwork are often cut or scaled back. Significant Investments Needed for New Programs: Starting a new CO program, either by rehabilitating a training center that is no longer in use or by building a new program within an existing HTI, is one strategy for scaling up the production of CO and CA graduates considerably. However, the requirements for both construction of infrastructure and the hiring of tutors are significant in both of these scenarios, and a large commitment of resources is needed if this is going to be a successful strategy for increasing enrollment. 2

10 Recommendations Based on the findings of this assessment, the MOHSW can scale up enrollment in CO and CA institutions by just under 5 percent with targeted investment in tutors, classrooms, and dormitories at each institution. Along with the institution-specific recommendations that are located in each institution report, a number of additional recommendations to the MOHSW and other stakeholders involved in building the capacity of health training institutions are found in this report. Recommendations for Scale-Up: Prioritize and focus scale-up efforts on a select number of institutions with the greatest potential for short-term improvement. Scale-up must happen in conjunction with appropriate increases in infrastructure, faculty, and teaching materials. Consider piloting innovative approaches to increasing enrollment such as developing a day program or experimenting with teaching students in shifts. Identify barriers to prompt and complete disbursement of funds to MOHSW institutions. When re-opening institutions, consider increasing intake immediately instead of focusing first on renovation of existing buildings. Recommendations for Recruitment & : Increase principal involvement in the selection process and develop strategies to increase local enrollment. Improve the system of tracking enrollment data at the HTIs and the communication of those data between HTIs and the MOHSW. Build a strong orientation program for clinical assistants to help students understand the importance of the clinical assistant cadre. Faculty Development Recommendations: Identify principal successors early so that they can be provided with leadership training. Develop a regular recruitment process for new tutors, including increasing capacity of tutor training institutions. Revise faculty standards to match the needs of the new CO/CA curriculum. Conclusions The immense need for health care workers in Tanzania has led to an incredible effort by the MOHSW and other government authorities to prioritize scaling up the enrollment of students at health training institutions (HTIs). Although the current government clinical officer and clinical assistant training institutions have scaled-up enrollment to assist the MOHSW in meeting its goals, the institutions have reached a critical point where significant investments in infrastructure and human capacity are needed in order to ensure quality education and produce high quality health care workers that can meet the needs of Tanzania s rural communities. With the new resources from Global Fund for AIDS, Tuberculosis, and Malaria (GFATM) Round 9, the MOHSW is well positioned to make a significant impact on the health care workforce shortage by scaling up the enrollment of HTIs. The recommendations from this report can help to guide these coordinated efforts. 3

11 INTRODUCTION, BACKGROUND, AND METHODS INTRODUCTION In July and August, 29, the International Training and Education Center for Health (I-TECH) conducted an assessment of the barriers and opportunities to scale-up enrollment at sixteen public health training institutions (HTIs) in Tanzania. Conducted as part of I-TECH s Human Resources for Health Scale-Up (HRHS) program, the purpose of this assessment was to help the Ministry of Health and Social Welfare (MOHSW) prioritize the resources available for scaling-up enrollment at HTIs. I-TECH was established in 22 with funding from the Health Resources and Services Administration (HRSA) in collaboration with the U. S. Centers for Disease Control and Prevention (CDC). I-TECH promotes activities that increase human capacity for providing HIV and AIDS clinical care and support through the development of health care worker training systems that are locally-determined, optimally resourced, highly responsive and self-sustaining in countries and regions hardest hit by the AIDS epidemic. The Ministry of Health and Social Welfare (MOHSW) and CDC requested I-TECH s technical assistance to integrate HIV and TB/HIV components into the curriculum for clinical assistants training centers (CATCs) and clinical officers training centers (COTCs). Beginning in 27, I-TECH integrated HIV and TB/HIV topics into the curriculum and developed teaching materials on these topics for three semesters. The ultimate goal is to enable the graduates of the training centers to provide quality care and management of HIV and TB/HIV. In complement to the curriculum development work, I-TECH is supporting a number of interventions to strengthen the capacity of pre-service tutors in 16 HTIs in teaching and facilitation skills and knowledge of fundamentals of HIV and TB/HIV. Additionally, I-TECH has worked with Zonal Health Resource Centers (ZHRCs) to increase training capacity of in-service training faculty. The new HRHS Program builds upon the work of these two programs, with the goal of supporting the MOHSW to address Tanzania s human resources crisis by increasing the number of qualified health care workers. This program works closely with tutors, principals, and students at public pre-service institutions training enrolled nurses, clinical assistants, clinical officers and laboratory assistants/technicians, in order to increase their capacity to train more new health care workers. The I-TECH HRH Scale-Up Program will support the MOHSW in its efforts to increase the enrollment of health training institutions through research and specific interventions aimed at addressing the roadblocks to scale-up. As part of this project, selected training institutions will receive a package of interventions, which may include infrastructure development, the hiring of additional tutors, leadership development, scholarships for students, and the purchase of teaching aids. I-TECH s efforts will focus on HTIs in the public sector under the authority of the MOHSW, recognizing that other partners will be supporting similar efforts in the private sector and faith-based training institutions. Before being able to recommend specific strategies for increasing the enrollment at pre-service HTIs, data are needed on the current barriers and opportunities to scaling-up enrollment at existing institu- 4

12 tions. The purpose of this I-TECH report is to provide institution-specific data on the twelve public CO and CA institutions, in order to assist the MOHSW in determining the most effective way to increase the output of this cadre of health care workers. This assessment had the following objectives: To document the existing capacity for student enrollment and retention at MOHSW CO and CA pre-service training institutions; To identify opportunities to increase both short-term and long-term enrollment and retention capacity at government CO and CA institutions; To document factors limiting short-term and long-term enrollment and retention capacity at visited institutions; To recommend interventions necessary to overcome limiting factors. BACKGROUND Defining the Health Care Workforce Crisis The global shortage of health care workers is threatening the success of key health and development goals in low-income countries throughout the world. The magnitude of the global crisis is well documented. In 26, the World Health Organization identified 57 countries with critical shortages of doctors, nurses, and midwives, 36 of which are located in Africa (WHO 26). The Joint Learning Initiative estimates that more than one million new health care workers are needed in Sub-Saharan Africa alone, which is almost triple the number of workers already in place (JLI, 24). The health care workforce crisis is defined by more than just the absolute numbers of health care workers trained, deployed, and retained. The skills mix of existing health professionals and the maldistribution of health care workers between urban and rural areas are both major contributors to the scope of the crisis in many countries (WHO 26, JLI 24). In Tanzania, the health care workforce crisis has hampered the government s ability to meet its goals for improving the social and economic well-being of its population. Quality health services are a key component of comprehensive social services, yet the shortage of qualified health care personnel consistently restricts the efforts of the government to increase the quantity and quality of health services available throughout the country (MOHSW 26). In 27, the MOHSW launched the Primary Health Services Development Programme (PHSDP ) in order to address the unsatisfactory performance of the health sector. The PHSDP, or MAMM as it is known in Kiswahili, set a goal of establishing a dispensary in each village and a health center in each ward by 212. Meeting this goal will require a rapid increase in the number of health care workers to fill the existing staffing gaps within the health sector and appropriately staff these additional health facilities. The Government of Tanzania estimates that in 26 there was a shortage of over 9, health professionals in the public and private sector combined. This accounts for almost three-quarters of the health care workforce (MOHSW 28). Through the MAMM, Tanzania plans to build 3,88 dispensaries, 19 district hospitals, 95 maternity waiting homes and 2,74 health centers to address the unmet need for primary health care services in Tanzania. The number of new professional health care work- 5

13 ers required to staff these additional facilities is estimated to be almost 9,, bringing the total new health care workers needed for the public sector alone to 144,74 by 217 (MOHSW 28). The efforts to scale-up training, recruitment, and retention of health care workers must be ambitious and comprehensive in order for the MOHSW to meet MAMM s objectives. Between 25 and 28, the Prime Minister s Office for Public Service Management (POPSM) approved 12,4 new positions within the health sector as a way to help absorb unemployed health professionals. In the 199s an employment freeze and budget ceilings led to a glut of newly trained health care professionals with no opportunities for public sector employment. Many trained health care workers were forced to leave the sector for other employment opportunities (MOHSW 28). As this pool of unemployed health care workers are absorbed back into the system, the MOHSW must increase the production of new health care workers in order to fill the new positions created by POPSM. Scaling up at Health Training Institutions One of the most effective long-term strategies for increasing the number of qualified health care workers available to fill the vacancies in the health sector is to increase the number of students enrolled in HTIs. This strategy is also one of the most time-consuming; experts estimate that it will take at least a decade to achieve meaningful increases in training capacity in Tanzania (McKinsey 26). Tanzania has 116 HTIs which train future health care professionals in both degree and non-degree programs. Tanzania s current training capacity cannot keep up with population growth and attrition in the health sector. Without significant interventions to increase the number of health care workers trained, Tanzania will actually experience a decline in HRH on a per capita basis (McKinsey 26). In 27, Tanzania s HTIs had produced a total of 23,474 graduates in all cadres over a ten-year period, only 16 percent of which were employed in the public sector (MOHSW 28). The MOHSW s objectives under MAMM call for an increase in HTI enrollment over a 1-year period from 1,13 students to 1,499 (MOHSW 27). The MOHSW HRH Strategic Plan projected that new enrollment in pre-service institutions would reach more than 6, students by the middle of 28 (MOHSW 28). However, the rapid assessment of enrollment trends conducted for the HRH Working Group in 29 showed that in September 28 the new enrollment rate was only 3,831 students instead of the targeted 6,45 students (MOHSW 29). Although the growth from 1,13 student to 3,831 students was substantial, the planned building of dispensaries and health centers through MAMM require that the MOHSW and its partners keep expanding training capacity in order to fully address the human resource crisis in the health sector. As the chart below indicates, if the enrollment trend continues at only 6 percent of the MAMM targets as it did in 28/29, the gap between actual HTI enrollment and projected enrollment needed will continue to increase. Swift action is needed to correct the course of the current trend in enrollment, which is falling short of projections and targets. In order to meet the targets set in MAMM, Tanzania must continue to aggressively increase enrollment capacity at the HTIs, and these increases will not be possible without a significant investment of resources and a clear strategy for addressing priorities. 6

14 Figure 1: MAMM Target, 29 Study Findings and Projections (MOHSW 26, MOHSW 29) Although some steps have been taken to meet the objectives as laid out in the MAMM, the resources have not been available to fully implement the MOHSW s plans for increasing enrollment in HTIs. The Ministry increased the training capacity of existing pre-service institutions with very limited additional resources; however, most pre-service institutions have not been able to double the size of the student body with their current infrastructure. Institutions report that they are strained by trying to train large groups of students without sufficient clinical faculty, administrative staff, classrooms, dormitories, library and resource materials, or computers (I-TECH 28, I-TECH 21). An assessment of 39 institutions by the Touch Foundation found that there were some common constraints to scale-up, including shortage of faculty, inadequate non-clinical and clinical infrastructure, and limited financial resources (Touch Foundation 29). In order to address the lack of resources for meeting scale-up targets, the Government of Tanzania successfully solicited significant resources from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM) Round 9. A portion of these funds will be used to support health system strengthening activities and goals. One of the key objectives of this funding is to increase production of mid-level and highly skilled health care workers in Tanzania s existing public, private, and faith-based training facilities. With the funds received from the Global Fund, the MOHSW plans to see student intake in HTIs increase from 351 to 6885 over five years. Demand by potential students does not seem to be a barrier to scale-up, at least for many of the training institutions. According to the Director of Allied Health at the Ministry of Health and Social Welfare, 576 individuals applied for only 255 spaces available in clinical officer training institutions in 29. During the same year, 167 applications were received for 35 spaces in the newer clinical assistant cadre (personal communication, 2 Nov 9). 7

15 Shortages of Clinical Faculty The shortage of full-time clinical faculty - who are often called tutors in Tanzania - is consistently identified as a critical barrier to scaling up enrollment at HTIs. Existing institutions are requested to double their intake and formerly closed training institutions are re-opening to meet MMAM s objectives. However, the number of tutors has not increased to keep up with this intake. Rather, the production of new permanent tutors is declining, and the current pool of practicing tutors continues to decrease in size (MOHSW 28). The HRH crisis also affects the HTIs themselves. According to the HRH Strategic Plan, public health training institutions had the highest percentage of unfilled positions among all health facilities. In 26, 1,711 health professionals were required to staff the 72 public health training institutions, but 74 percent of those positions were unfilled. In comparison, the vacancy rates at dispensaries, health centers, and district hospitals were 69, 59, and 67 percent respectively (MOHSW 28). The MOHSW enrollment study also shows significant staffing gaps with very few new full-time tutors posted to HTIs in the last two years. The staff deficit at the 56 institutions that provided selfreported data was 19 full-time faculty; an estimated gap of 45 percent in the overall teaching faculty at HTIs (MOHSW 29). Despite this gap, only 32 new full-time faculty had been posted to these 56 institutions over the past two years (MOHSW 29). One of the factors contributing to the low number of new faculty posted to training institutions is the lack of clinical health care professionals choosing to enter the teaching profession. at the three faculty training centers that provide training in teaching methodology declined to 52 percent of capacity in 29, with a total of only 47 new clinical faculty currently enrolled in faculty training programs (personal communication with training institutions, November 29). Assessments by I-TECH found that the shortage of clinical faculty further compounds low morale among existing faculty by increasing the workload of individuals who are discouraged by low salaries and the lack of opportunities for promotion and further training (I-TECH 29). When 129 tutors at CO/CA institutions were asked about training opportunities they had received, on average they had attended only two courses, trainings or workshops during their entire teaching career. Most of the trainings were provided by the MOHSW or I-TECH in the past two years. Exactly 5 percent of these tutors had been teaching for six to eleven years, or more (I-TECH 29). Geographic Maldistribution of Health Care Workers Maldistribution of health care workers between rural and urban areas is another key contributor to the HRH crisis in Tanzania. Although the majority of the population is found in rural areas, the most highly skilled health care workers are more concentrated in urban areas. There are 53 physicians and 43 AMOs per million people in urban areas, and only 17 physicians and 16 AMOs per million in rural areas (McKinsey 26). Creating more HTIs in rural areas and increasing enrollment of students from the region could assist in increasing the number of trained health care workers working in rural areas. A considerable body of research from both high-income and low-income countries shows that growing up in rural areas increases the likelihood of future rural practice (Rabinowitz 1999, Rabinowitz 21, Dussault 26, de Vries 23, Lehmann 28). Other studies show that training in a rural location and exposure to 8

16 rural health issues during training also increase the probability of future rural practice (Burfield 1986, Rosenblatt 1992). Establishing additional training institutions in rural areas, investing in expanding those already in rural areas, or increasing the amount of fieldwork for health professional students could help to address maldistribution of the health care workforce. Efforts to increase rural retention and recruitment should ideally focus both on selecting appropriate candidates and also providing them with sufficient opportunities to explore rural practice experiences during their training (Rabinowitz 2, Brooks 22). The Importance of Mid-Level Cadres Many countries facing HRH shortages are increasing their production of mid-level cadres or non-physician clinicians (NPCs). NPCs are clinical health care workers who have training beyond secondary institution, with fewer clinical skills than physicians but more than diploma level nurses (Mullan 27). The time period between the enrollment of students at HTIs and when they actually enter the health care workforce creates a challenge for countries like Tanzania that have already reached a critically low density of health care workers. As a result, NPCs have become central to HRH scale-up efforts in many countries, as they are generally trained with less cost and in a shorter amount of time than physicians (Mullan 27). A review of the role and training of NPCs in 47 Sub-Saharan African countries also found that training for NPCs is more focused on local and indigenous health challenges, making them uniquely qualified and equipped to work in community-based health facilities and outside of district or regional hospitals. This same review also found that NPCs were more likely to be recruited from rural areas, and trained and placed in jobs closer to their geographical origins which is also conducive to meeting the needs of health centers and dispensaries (Mullan 27). NPCs, such as assistant medical officers (AMOs) and clinical officers (COs), play a very important role in delivery of health services in Tanzania. AMOs are able to perform about 6-8 percent of the clinical work of physicians (McKinsey 26) and are often the only clinical staff at hospitals in rural districts. COs perform basic clinical work at lower level health centers and dispensaries throughout the country (I-TECH 28). In 26, there were about 1 AMOs and over 6, COs in Tanzania. In contrast, there are only about 9 physicians, and many of those are serving in administrative or government positions and no longer involved directly in patient care (McKinsey 26). Most importantly, there is a critical shortage of clinical officers, nursing officers, enrolled nurses, and laboratory assistants in Tanzania as shown in the table below. These four cadres make up almost 85 percent of the current adjusted deficit of health care workers in Tanzania. Clinical officers account for about one-third of the current deficit of health care workers in Tanzania, and nursing officers account for almost one-quarter of the deficit (CSSC 29). With 28 enrollment numbers, Tanzania can expect to have vacancy rates of 74 9 percent by 218 in these critical cadres. Any efforts to address the health care workforce crisis in Tanzania should consider these crucial cadres for maximum impact. 9

17 Table 1: Projections of Health Care Workers Needed for Regional Hospitals and Lower Facilities by Selected Cadres (MOHSW 29) Adjusted Deficit* Production Estimate (27/8 217/18) from current HTIs Estimated vacancy rates by 218 at current production Clinical Officers 33,12 5,495 83% Nursing Officers 21,263 2,17 9% Enrolled Nurses 17,33 4,48 74% Laboratory Assistants 14,932 2,96 8% * Adjusted deficit takes into account attrition and output to the private sector. However, it does not consider the planned building of new health centers and dispensaries throughout Tanzania, which will further increase the deficit. Clinical Officers and Clinical Assistants in Tanzania Of the 116 HTIs in Tanzania, 16 train clinical officers and clinical assistants. There are five public clinical officer training institutions in Tanzania and six public clinical assistant training institutions. There is also one new clinical assistant training institution in Mpanda, which is being renovated and opened for enrollment in 21 or 211. CA and CO training institutions are located throughout Tanzania, and are generally located at the district level. According to Strategic Objective 3.1 of the Human Resource for Health Strategic Plan, the MOHSW introduced the clinical assistant cadre and scaled up the production of enrolled nurses as a way to increase the number of health care professionals serving at the community health level (MOHSW 28). Clinical assistants most closely resemble an older cadre known as rural medical aides (RMAs) in purpose and in their two-year length of study. Though the MOHSW stopped training new RMAs in the late 199s, there are still RMAs working throughout Tanzania, though many are trying to upgrade to become clinical assistants and clinical officers. Like Rural Medical Aides, clinical assistants are intended to serve primarily at the village and dispensary level. However, clinical assistants have higher pre-requisites for secondary education than rural medical aides, due to the overlap between the new clinical assistant and clinical officer curriculum. The MOHSW determined that the best way to develop the clinical assistant cadre was by shortening the course of study for clinical officers. Clinical assistants and clinical officers also have very similar pre-requisites and are all Form Four Leavers, meaning they have completed four years of secondary school. Generally the strongest candidates are selected for the clinical officer track. In 27, the three-year curriculum for clinical officers was revised extensively by the MOHSW, using a National Technical Awards (NTA) level framework designed by the National Council for Technical Education (NACTE). An exit point was created in the curriculum for clinical assistants after two academic years of study. As a result, clinical assistants and clinical officers use exactly the same curriculum for the first two academic years, with clinical officers completing an additional, third year of study. In 28, the existing clinical officer training institutions were also divided into those training either clinical officers or clinical assistants. The first class of clinical assistants completed their course work and took final exams in late 29, so time is needed before the full impact of this new cadre can be measured. 1

18 Figure 2: Location of COTCs and CATCs in Tanzania (Indicated by blue triangles) Selection Process for Public Allied Health Students The selection process for allied health professional students at public institutions is managed by the Directorate of Human Resource Development (HRD) at the MOHSW. All interested candidates apply directly to the central MOHSW where their applications are reviewed and their credentials verified. The MOHSW produces the list of students accepted to each institution and notifies candidates. This process is called first selection. Each year, between 15 and 3 percent of accepted students from the first selection decide not to attend the HTI where they were placed. About two to three weeks after the reporting date for clinical officer and clinical assistant students, the HTIs report the number of students that arrived at the institution during first selection and the number of spaces remaining to be filled. The MOHSW reviews the list of qualified candidates and selects another set of students to be placed at the institutions during second selection and notifies those students who then report to the institution, if they still want a space. The time between when the first students report to the institution and when the final second selection candidates arrive can take between one to two months. 11

19 Registration of Allied Health Training Institutions The quality of technical training institutions is coordinated and monitored by the National Council for Technical Education (NACTE). All training institutions falling under NACTE s jurisdiction must be registered by NACTE before they can begin enrolling students. NACTE s registration process considers the adequacy of infrastructure, faculty, funding, curricula, governance, support services, long-term planning, and other factors. Each training institution is scored based on the registration criteria using the data in their application form and physical verification through a site visit from a NACTE authority. In order to commence training an institution must receive at least a provisional registration from NACTE by scoring a minimum of 3.5 out of 5. on the registration criteria. A score of 4.3 or above will provide full registration. All but one of the visited clinical officer and clinical assistant institutions currently enrolling students are fully registered by NACTE. Registration is the first step in accreditation, which is also managed by NACTE. This is an on-going process, with full accreditation for each institution as the ultimate goal. At the time of this report, none of the visited institutions had received full NACTE accreditation. METHODS While the MOHSW has detailed plans for ways to meet the nation s demand for more health care workers, there are few data illustrating the barriers and opportunities to scaling-up enrollment at specific health training institutions. Most CO institutions report that they have increased enrollment as much as possible with current infrastructure (I-TECH 28). Clear institution-specific action plans are needed to galvanize resources and address significant bottlenecks, so that the MOHSW s bold scale-up plan will reach its targets. In response to the need for data to inform the MOHSW s efforts, several partner organizations are studying enrollment trends and possible ways to scale-up enrollment. In 29, the Christian Social Services Coalition (CSSC) and the Canadian International Development Agency (CIDA) conducted assessments of strategies for increasing enrollment capacity at private, faith-based pre-service institutions. In 28 and 29, the Touch Foundation conducted a detailed assessment of 39 HTIs in 14 regions of Tanzania. Both assessments found that specific interventions, such as tutor hires or construction of new facilities, could increase the output from training institutions, but that the specific needs of each institution varied. The Touch Foundation assessment also recommended programmatic changes such as staggering classes of students as a way to increase enrollment (Touch Foundation 29). Only three of the institutions assessed by the Touch Foundation were public CO, CA, or EN institutions under the authority of the MOHSW, leaving a gap in the data available on these institutions. Using modified versions of the tools developed by the Touch Foundation as well as additional tools, I-TECH conducted an assessment of all the government clinical officer and clinical assistant training institutions in order to develop institution-specific action plans. The primary focus of this assessment is clinical officer and clinical assistant institutions, but the assessment team also visited one AMOTC, which had been identified by the Touch Foundation as a potential location for a new CO program. 12

20 Data Collection The assessment was conducted between July and August of 29. Teams comprised of one I-TECH representative and one Ministry of Health representative visited all twelve public clinical officer and clinical assistant training institutions, including one new clinical assistant training institution that is scheduled to open in 21. One of the teams also visited one AMO training institution that had been identified as a possible site for a new CO training program. Prior to the visit by the team, an Institutional Questionnaire, adapted and augmented with permission from the Touch Foundation s tool, was sent to the principals of all of the public CO/CA institutions in operation the during 28/29 academic year and to the one AMOTC. The Institutional Questionnaire was not sent in advance to those institutions that had not yet started to enroll students. This self-administered questionnaire collected data on student enrollment trends over the past four years, infrastructure available on campus, finances, and staffing (see Appendix 2 for data collection tools). The teams also reviewed institution and zonal plans where available, as well as any prior site visit or assessment reports conducted by I-TECH or other institutions. The teams spent one day at each institution. During the site visits, the teams conducted a semi-structured interview with the principal or acting principal at the institution. The questions in this interview were designed to collect data from the principal on the institution s ability to enroll additional students while maintaining a quality experience for the students. In some cases, additional full-time faculty members joined the principal interview to provide input on certain aspects of the discussion. The teams also toured the facilities at the institution, documenting the available infrastructure at the institution through photographs and notes. Where possible, the study teams also conducted focus group discussions with 8 to 12 students at the institution to learn about their experience as students (see Appendix 2 for focus group discussion guide). In most cases these students were chosen randomly, but in some cases where classes were not in session the principal identified one or two students to recruit the group discussion participants. Institution faculty and staff were not present during these discussions. In some cases students were not available for a focus group discussion during the visit by the study teams due to fieldwork or a break in the academic calendar. During the site visits, the teams also collected copies of financial reports, business plans, academic calendars, and other supporting documents regarding the operation of the institution. Because the hospital plays an important role in the clinical training of students, the teams also visited the hospital to interview the medical officer in charge or the acting medical officer in charge to gather data about the ability of the hospital to provide effective clinical training to the students at the institution. In some cases, the Regional Medical Officer also met with the visit team and provided his/her perspective on scaling up enrollment at neighboring training institutions. Following the 29 site visits and during the drafting of this report, I-TECH followed up by phone and with the principals of all CO and CA institutions to collect their first selection, second selection, and final enrollment numbers for the 29/21 academic year. I-TECH was represented by either Dila Perera, HRH Scale-Up Manager or Emily Bancroft, Quality Improvement Consultant at all the site visits. The MOHSW participants were Ndementria Vermund, Veronica Mpazi, Dennis Busuguli, Dr. Sadock Ntunaguzi, and Dr. Edward Kija. 13

21 Table 2: Data Collection Summary Method or Activity Purpose Number/ Representation Desk Review Review of Zonal strategic plans, MOHSW HRH assessments, Partner-led assessments, and pre-service site visits to six CA/CO institutions Institutional Questionnaire Structured, self-administered by principal and other staff (mailed in advance of visit) Site Visits 1 day visits to public CO and CA pre-service institutions, and one AMOTC as a possible site for an additional CO program Principal Interview Semi-structured interview with principals and available tutors at HTI Medical Officer in Charge Interview Semi-structured interview with medical officer in charge and/or matron of adjoining hospital To collect information on institution plans, priorities and needs and to provide background to study team members To collect self-reported institutional information on enrollment, fees, infrastructure, finances, and staffing from principals To assess infrastructure and human resources at each institution firsthand, as well as meet with tutors, principals, and students To review information collected in institutional questionnaire and discuss challenges/opportunities related to scale-up in greater detail To assess impact of current student enrollment and future scale-up on clinical instruction and care at teaching hospitals All eight available strategic plans and seven business plans From each of the 12 visited operating institutions (not collected from the one newly reopening CA institutions) 12 eligible, public, pre-service institutions for CA and CO, and 1 AMOTC From each of 13 visited institutions From each of the 13 hospitals adjoining the visited institution Student Focus Group Semistructured focus group discussion with random sample of students Tour & Observation Facility tour to observe and photograph infrastructure Secondary Document Review Review of documents from institutions not provided during visit: financial plans, academic calendars, confirmation of enrollment data, especially of local students To collect information on student life and learning To provide documentation of existing infrastructure at each institution To collect and clarify information collected from visited institutions 71 students from eight CO/CA institutions At each of the 13 visited institutions 13 visited institutions Analysis The qualitative data from interviews, focus groups and observations were compiled, typed, and reviewed by the team members immediately following the site visits. Data from the institutional questionnaires were entered into a spreadsheet for analysis. Data entry was checked by the two I-TECH team members for each of their institutions to ensure that information from the instruments was captured accurately. Qualitative responses from semi-structured interviews were analyzed according to themes and recurring responses to develop overall findings and recommendations. Institution specific data were reviewed to look for inconsistencies between questionnaires and in-depth interviews. I-TECH 14